Subjectivity in psychiatric diagnosis and the implied prevalence of misdiagnosis

Craig A. Napolitano Prof. Fisher May 11, 2005

Many obvious problems arise because psychology is not a physical science yet it is often treated as such. At one time clinicians’ diagnoses relied upon nothing more than what equated to a gut feeling or at best how closely a patient was representative of stereotype for a known mental illness. Questions about the subjectivity in psychiatric diagnosis did not come about until the early to mid 1900s when it became clear that different states’ medical boards had greatly varying pass rates for the psychiatric examinations of enlisted men, even greater than could be accounted for by random population variance alone. Studies quickly began to show that rates of agreement between diagnosticians were appallingly low calling even the question of the validity of labeling patients with common mental disorders into question. The studies spawned an effort to increase diagnostic reliability and in turn validity by bringing the Diagnostic and Statistical Manual of Mental Disorders into widespread acceptance through near total revision (in DSM-III). While reliability was undoubtedly increased, human bias nonetheless remained in several forms. Everything from a clinician’ personality to the socioeconomic status of patients has proven significant in skewing diagnostic objectivity. Although today professionals are very well aware of the shortcomings of even a well developed diagnostic system, the current mental health reimbursement system and the alarming rates of bipolar and ADD/ADHD in this country illustrate a field that still has much to reform even though perfection can never be fully achieved. Many people have questioned the purpose in labeling patients with a mental diagnosis in the first place. Surprisingly members of all three schools of psychological thought have questioned the need for diagnosis in treating patients. The least surprising argument comes from the humanists who feel labeling is not only dehumanizing, but

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takes away from the differences that each case presents with. Psychoanalysts say that overall labels do not adequately describe a patient’s personality dynamics and, therefore, cannot effectively be used in the development of psychoanalytically orientated treatments. The behaviorist Yates wrote that “with but a few exceptions, the search for a diagnostic label is completely futile (since it has no etiological or treatment implications) except for research purposes.” (1) Yates was entitled to his opinion; however, he underscored the several more important reasons for diagnostic labels. When a patient is successfully categorized, the diagnosis can aid in predicting future behavior, which is of magnanimous value when considering possible suicide attempts in the case of major depression. There is no doubt that diagnostic labels allow for communication between various professional. It is understandable that generations ago this may have not been needed for the town doctor working alone, but considering the level of cooperation between clinicians today, a world without such simplicity cannot be imagined. By using a single word or phrase for a diagnosis, time and energy is saved in place of having to give a lengthy narrative over the phone for each patient as similar as they may present. “Without the use of such diagnostic labels, psychologists would not be able to rely on the accumulated wisdom of the field’s clinical and research experience, and would have to ‘reinvent’ psychology for each and every patient.” (1) Therefore, it will be assumed in the rest of this discussion that diagnostic labeling is not only essential to the fields of psychology and psychiatry, but in fact required for progress to be made. In an attempt to quantify the magnitude of subjectivity in clinical psychology, research has focused on the two major categories of reliability and validity and their reliance on one another. Validity refers to a distinction between categories that can be demonstrated. This distinction should be “real” and “important”, i.e. not skin color. (1)

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Reliability refers to the degree of agreement between different observers or the ability of data to be reproduced in general. Reliability places the upper limit on the validity that be achieved with a test. (1) The Boisen study of 1938 looked at the prevalence of hebephrenic schizophrenics in mental institutions across three different states. The rates of prevalence of this particular diagnosis in the studied mental hospitals varied from 15.5% to 45% of a hospital’s total population when comparing the three states in question. Furthermore, within one state alone the prevalence of this single mental disorder ranged from 11% to 76%. (1) Clearly, such variation could not occur by chance. The Mehlman study of 1952 hoped to find agreement among broad categories, such as organic versus psychogenic disorders and manic depressive versus schizophrenic disorders. It studied around 4,000 male and female inpatients and found a great variability between the frequencies with which different clinicians assigned patients to these broad categories. (1) Pasamanick et al. (1959) studied 538 women across three different wards within the same mental institution. Even with no demographic differences found among the women, the prevalence of schizophrenia ranged from 23% to 36% for the three different wards. During the timeframe of the study, one ward alone had three different administrators and also a 22% to 67% variation in the incidence of schizophrenia. (1) Other studies focused on the rates of use of specific labels between different countries. Sandifer (1968) filmed the diagnostic interviews of 30 patients and showed the films to psychiatrists in North Carolina, London, and Glasgow (Scotland). A pattern quickly emerged and it was found that the clinicians from North Carolina often used the label neurotic whereas those in Glasgow overused personality disorder and manic depressive in Britain. (1) The Katz study of 1969 videotaped one female patient and

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played it for clinicians in both America and England. The Americans were divided among the diagnostic labels of schizophrenia, neurotic, and personality disorder; where as English clinicians primarily gave a diagnosis of personality disorder never even mentioning schizophrenia. Clearly this data paints a picture of differing definitions of mental diseases among different healthcare systems. Kendall (1971) went on to conclude that Americans overuse the label of schizophrenia. “…The concept of schizophrenia held on the east coast of the United States now embraces what in Britain would be regarded as depressive illness but also substantial parts of several other diagnostic categories – manic illness, neurotic illness and personality disorder.” (1) Further reliability research was in general broken down into two categories: those focusing on test-retest reliability and those on inter-rater reliability. Even if all clinicians agreed on every diagnosis, one source of error would remain: test- retest reliability. Diagnoses have been shown to not only change with time, but even differ depending on what day of the week they are made. The Masserman study of 1938 followed 114 patients up to one year after discharge from a psychiatric facility. The classifications changed in the case of 41 different patients. The subclasses of schizophrenia even changed for 12 of the 18 patients labeled as schizophrenic. The Ash study of 1949 studied the diagnoses of 3 psychiatrists on 52 patients for major diagnostic categories. For the major categories the three agreed only 45.7% of the time. For the sixty specific categories, they agreed a mere 20% of the time. (1) In Goldfarb (1959) four psychologists diagnosed 100 different veterans. Among five broad categories, it was found that the chance any two of the four psychologists would agree was 60%. This estimation of a 60% rate of agreement was corroborated by later studies. Norris (1959) found a similar 60% agreement for over 6,000 patients interviewed weeks after their discharge from psychiatric institutions. The

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rates of conformity ranged from 80% for organic psychoses, 54% for neuroses, and a low 43% for character and behavioral disorders. (1) Krietman (1961) also arrived at a 63% agreement among clinicians, with rates varying from 75% for organic disorders to a dismal 23% for neuroses. Overall, trends were found that rates were highest for broad categories versus specific diagnoses and rates were unacceptably low for neuroses and personality disorders. Many inquires took place in order to better understand such low rates of interrater agreement. In the process the Kappa coefficient was devised by Cohen in 1960. To more accurately account for the data, the percent of observed agreements greater than by chance alone was divided by the number of non-chance agreements. (1) Spitzer and Fliess in 1974 used this new tool to reanalyze data from six earlier studies. Its general conclusions were that the Kappa value for organic brain syndromes was a much higher 0.77 than 0.32 for personality disorders. Spitzer concluded that there was no single category with a high reliability and that the current criteria for diagnoses were only satisfactory for mental deficiencies, organic brain syndromes, and alcoholism. (1) Before long the sources of such undeniable systematic errors were analyzed. Ward (1962) estimated that 62.5% of disagreements were due to limitations of the current system used for classification. Likewise, it attributed only 32.5% of errors to the clinicians themselves and the remaining 5% to the patients. While the DSM-II appeared a great scapegoat for such embarrassment, its method of classification was undeniably subjective. “[In DSM-II] diagnostic stereotypes are described under each category. The task of the diagnostician then becomes one of selecting the diagnostic category in which the stereotype most closely resembles the characteristics of the patient being diagnosed.”

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(1) Fortunately, the research and effort proving the inability of the current system was matched by recommendations for better diagnostic criteria. Reform began in the form of the Research Diagnostic Criteria (or RDC) developed by Feighner et al. in 1972. Although it focused on only fifteen psychiatric disorders, it was unique in that it included clinical descriptions as well as lab studies, other similar disorders (now referred to as the differential diagnosis), follow up studies, and even family studies, which attempted to see if the diseases described were at all genetically inherited. (1) It specifically reduced subjectivity by requiring a minimum number of symptoms in each case for the diagnosis to be applied. In addition, it included symptoms, which would automatically rule out certain diagnoses. Researchers were anxious to try this new method and early results were promising. In one study of 314 patients that presented to a local emergency room, there was an 86% to 95% agreement between staff. The test – retest reliability was an amazing 93%. Around the same time, Spitzer et al. (1978) developed a structured interview called the Schedule of Affective Disorders and Schizophrenia (SADS). It results correlated with Kappa values ranging from .68 to a perfect 1.00. (1) News of the promise of new methodologies spurred the most drastic revision of the DSM in history: the DSM-III. Spitzer was appointed the chair of the committee in charge of the producing the new edition. The DSM-III was unique in several respects. It created thee Axes for diagnosis. Axis I dealt with clinical symptoms, Axis II with personality and developmental disorders, Axis III for physical manifestations of psychological conditions, and finally Axes IV and V for the severity in the presentation of the diseases and surrounding factors. (1) It recommended that clinicians dually diagnose both a clinical disorder and a personality one in order to better describe the patient and consider the important role of

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each. A later study by Spitzer himself in 1979 estimated the reliability of Axis I to have promising Kappa coefficient of 0.78 followed by 0.61 for Axis II. His test – retest reliability studies arrived at a similar Kappa value of 0.66. (1) A recent article in The New Yorker even described the tale of the creation of the DSM-III under the supervision of Spitzer. He was quoted saying, “Without reliability the system is completely random, and the diagnoses mean almost nothing-maybe worse than nothing, because you’re falsely labeling. You’re better off not have a diagnostic system. The committee, given the task of revamping the DSM, benefited greatly from Spitzer’s quirky nature and intense desire for improvement. A colleague referring to Spitzer stated, “He doesn’t understand people’s emotions. He knows he doesn’t. But that’s actually helpful in labeling symptoms. It provides less noise.” (2) What resulted was a revision of the DSM that included several new diagnoses used commonly today, such as ADD, autism, anorexia nervosa, bulimia, panic disorder, and post-traumatic stress disorder (PTSD). When asked of the internal criteria Spitzer used in accepting new labels, he simply stated, “How logical it was, whether it fit in. The main thing was that it had to make sense. It had to be logical.” (2) Modeled in part after the RDC developed earlier, the DSM-III added a checklist of symptoms for each disorder and enumerated how many were required for each specific diagnosis in order to combat subjectivity directly. This was such a dramatic change from the prior versions, that Gerald Klerman, a well known psychiatrist at the time, exclaimed, “The reliability problem has been solved.” (2) While the promise and hope the DSM-III inspired in the psychiatric community was palpable, researchers looked for weaknesses in the new system. Spitzer himself had concluded in 1979 that it produced only “fair” reliability for Schizoaffective Disorder, Chronic Minor Affective Disorder and personality disorders. (1) Kutchins et al. (1986)

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complained that only small patient pools were used in the analyses of its effectiveness and, therefore, further proof was needed to confirm its contributions to reliability. However, the most unanimous criticisms of the new DSM-III focused on its lack of reliability for disorders in children. For most of the children’s disorders it listed, it did not use the same empirically developed classification system that was the hallmark of the new DSM-III. In addition, many clinicians complained that it left out “masked depression” and “symbiotic psychosis”, which were commonly used labels of the time. (1) Many also agreed that the overlap in symptoms describing the various personality disorders automatically reduced its reliability in this area. During the search for improvements in reliability, research also focused on the equally important discussion of validity in diagnostic labels. The first to question validity historically was Meehl. In a 1960 report he published, “He described research results which found that clincians’ impressions of clients are formed early and remain relatively unchanging despite additional information.” (1) This raised the discovery of the first problem in human clinical judgments: confirmatory bias. The basis behind this type of error is that “people in general tend to look for evidence to confirm their hypotheses and tend to ignore or to undervalue disconfirming evidence.” (1) Confirmatory bias was first discovered by Wason (1960) when he asked subjects to devise a pattern for strings of numbers given. He found that subjects listed sequences that corroborated their initial hypothesis and tended to ignore sequences that disconfirmed their hypothesis. (1) One famous study confirms this assumption specifically in the realm of clinical diagnosis. The Rosenhan study of (1971) involved normal people pretending to have heard voices in order to obtain admission to a mental institution under the label of schizophrenic. Once admitted, the patients behaved normally for three weeks until discharge. Even though

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there were no sufficient grounds to still classify these patients as schizophrenic at their exit interviews, the predominant diagnosis given was “schizophrenic in remission”, which implied that the patients still had it, but were now temporarily symptom free. (1) A similar type problem in clinical judgment is called anchoring. Similar to confirmatory bias, this simply implies that observers will rely more heavily on the information obtained initially because it is easier than to constantly and effectively assimilate new information. The famous Temerlin study of 1968 involved an actor who appeared normal, but a bit anxious to observers. He was interviewed by three different groups. In each, he was described differently as either a person applying for a job, as appearing psychotic or neurotic. Not surprisingly, the group that was told he was psychotic in general gave the most severe diagnosis. (1) Clearly, anchoring demonstrates the need for structured diagnostic interviews in which the clinician is prepared to accept information in several areas. A problem that especially plagued the DSM prior to the advent of the third revision is representative bias. This implies that judgments are primarily made based on how well a patient appears to resemble a stereotypical patient of a certain disorder. The room for subjectivity here is clear and with only descriptions present in the DSM-II, it is no surprise this was the basic technique used by many clinicians. Tversky (1974) implied that one of the best ways to combat representative bias was to consider the relative prevalence of each possible disorder. (1) If a patient appeared to be a stereotypical “X”, but 99% of these types of patients have “Y”, one should deliberate further before rushing to diagnose. Another dilemma concerning clinical judgment that most would agree is extremely prevalent today is availability bias. Even professionals have certain symptoms

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and labels that they consider first before others. This gives way to the idea that certain diagnoses are “fashionable” or looked for more often than should be expected in a given time period. In the U.S. nearly twice as many women are labeled as having depression as men. While this may point to a form of sexism in the current system, more likely clinicians are simply conditioned to expect it in today’s generation. (3) In addition, the diagnoses of bipolar and ADD/ADHD appear so rampant they imply these are simply the fashionable labels of our age neglecting the full differential diagnoses needed to accurately dispense these labels. The most significant trouble with clinical validity on the patient’s side is that they are prone to believing their initial diagnosis. Scheff (1966) described the “self-fulfilling prophecy”. He concluded that the public subconsciously reinforces label specific behaviors. “In this way, the diagnostic label, even though initially inaccurate, becomes accurate over time.” (1) In fact this idea is so prevalent that it has spawned a phenomenon known as the Barnum effect, in which people have the general tendency to interpret ambiguous statements as accurately describing themselves. Forer (1949) sent the same personality profile to all college students who filled out a personality survey. It of course used ambiguous statements, such as “You are often critical of yourself,” but was well accepted because students implied each response was unique to themselves. (1) Not surprisingly, the Barnum effect is named after B.T. Barnum because he was known to make cynical comments, such as, “There’s a sucker born every minute.” (1) This common problem introduces the idea that labeling can be harmful on patients. No discussion of psychiatric misdiagnosis would be complete without discussion of the harms of labeling. One must first consider whether it is true that diagnostic labels promote different emotional responses in others. A recent study by Wadley confirms this

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common belief although the results are contrary to popular belief. Its general conclusion was that “diagnostic labels significantly influence emotional responses, attributions, and willingness to help the individuals to whom these labels are attached.” (4) In addition, the responses depended on the specific nature of the diagnosis. When people were labeled as having Alzheimer’s disease, a mental deficiency known to have a biological origin, subjects had a greater sympathy than for a control patient exhibiting the same behaviors without this label. (4) The diagnosis of major depression was considered to have a psychological cause in the study and, as expected, resulted in some sympathy from the subjects, but not nearly as much as from Alzheimer’s disease. These results imply a pattern where people’s response to labels is matched by the level of blame that can be placed on the patients themselves. Naturally, people are most sympathetic and willing to help those who fall victim to a biological disease analogous to breast cancer or heart disease. Although people clearly discriminate based on diagnostic labels, it would not be a significant issue unless it often had grievous consequences. A paper entitled Stigma, Labeling and Psychiatric Misdiagnosis: Origins and Outcomes painted a much more dismal picture of the effects of misdiagnosis. “…People perceive mental illness as an indication of weakness or a cause for shame, fear that their lives or careers will be ruined if they seek help, and therefore many avoid treatment that could ease their suffering or even save their lives.” (5) It illustrates its point by describing a case in which an Israeli man is continually persecuted for his previous diagnosis. In fact the case vignette pays little attention to general social effects and focuses on governmental persecution. The man portrayed lost his military service and, analogous to the Rosenhan study, was unable to escape his initial diagnosis of schizophrenia even after performing satisfactory on

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batteries of tests performed by several different military and civilian psychiatrists. (5) In fact, according to the DSM-IV, he should have originally been labeled as suffering from major depression. In this particular case a cultural sensitivity would have been appropriate as well since he was raised by two anxious survivors of the Holocaust and this could account for his differing personality. The author of the paper ended with the conclusion that “when the examiner lacks an awareness and knowledge of the examinee’s social norms, he or she will often be unable to identify a mental disturbance correctly. Worse yet, he or she may arrive at a false interpretation and inaccurate diagnosis.” (5) Two areas of clinical judgment that have cannot be grouped into any specific category yet have an effect nonetheless are the specific characteristics of the clincians as well as of the patients. An APA study conducted in 1988-1989 found that psychiatrists tend to prescribe medications when they are younger, male, and have a larger patient load. (6) A recent study confirmed these assumptions by carrying out a national case vignette study with which demographic information was first obtained. The two questions in the case vignettes were whether the patients described should be diagnosed as suffering from depression and, as a result, if they should be treated with medication in addition to standard psychotherapy. 278 psychiatrists responded to the study and each was randomly given one of four cases with which to diagnose and choose a treatment plan. Each of the four cases differed in the severity of the presentation. The results had important implications because when the clincians gave a diagnosis of depression, they were 35 % more likely to order antidepressants as well. (6) Therefore, as opposed to the opinions of some psychologists, diagnosis does have a direct impact on treatment and cannot, therefore, be ignored or deemed unnecessary. The general characteristics found

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for those who said they would have prescribed antidepressants were being male, having a lower satisfaction with their practice, having a higher percentage of patients on managed care, and often prescribing both psychotropic and non-psychotropic medications. (6) In this study, the patient’s demographics and other unique characteristics were ignored in order to look for only variations in clinicians; however, patient characteristics can have as great of an impact on diagnosis and, as shown here, ultimately their treatment. Several studies have considered the potential clinician bias when patients are of a different social status, race, or sex. Abramowitz et al. (1977) found only a patient’s social status and not race or sex to have a negative impact on diagnosis. (1) However, it admitted that the strongest predictor of misdiagnosis was a difference in the value system between the clinician and patient. Therefore, this implies race (because of differing cultures) may appear to have a negative effect on the accuracy of diagnosis. In a study of several different mental hospitals, blacks were almost always assigned schizophrenia over affective disorder. (7) Even when controlling for age, sex, and social class, one study revealed a 39% prevalence of schizophrenia among blacks and 18% prevalence for whites at the same institution. The Welner study focused on follow up diagnoses for both white and black patients in 12 different categories. Follow up diagnoses differed from original impressions for 46% of black patients and only 25% of white patients implying an inability to agree on diagnoses for blacks among different white clincians. (7) More startling was the Dehoyos study that counted the average lengths of admissions notes for mental institutions. On average, clincians used more than 18 lines to explain why white patients should be admitted, but less than 13 lines for why blacks should be admitted. In one particular note, a clinician wrote a 49 line admission note for a white middle class male likely because the psychiatrist could most closely associate with such a patient and

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in turn be most sympathetic to his or her plight. (7) The study also found that clincians wrote shorter admissions notes for patients of greatly different age and/or social class confirming the “distance to the patient” hypothesis. Further studies aimed at figuring out why clincians had such difficulty in dealing with black patients. The Schneider study found that blacks were much more greatly associated with having delusions or hallucinations. (7) This could likely explain the greater prevalence of schizophrenic diagnosed in black populations because hallucinations are often used as the primary criteria for the diagnosis of schizophrenia. Hallucinations were found to be more prevalent in both schizophrenic and undiagnosed/mentally healthy blacks implying that there exists an ethnic difference in the meaning of hallucinations among different cultures. (7) White clincians also in general describe blacks as less emotional and, therefore, have difficulty in reading the subtleties of their facial expressions during interviews. Even tests, such as the MMPI (not elaborated on), have higher baseline scores for blacks. (7) Fortunately, research following the advent of the DSM-III has shown similar rates of diagnoses among white and black patients likely due to the more objective and precise definitions used. While discussion of clinical reliability and validity appear to be more historical considering the acceptance of the new methodology of the DSM in the early 1980s, several problems persist to this day reaffirming the need for discourse in these areas. As most would agree, bipolar and ADD appear to plague our country at this particular point in time. In addition, as critics of the DSM-III first pointed out, diagnosis in children can be much more difficult due to the relative lack of research in this important age group. “Under diagnosis of bipolar disorder may lead to under-treatment, or the provision of appropriate medical and psychosocial services to only the most severe patients.” (8)

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Diagnosis of bipolar in a child only technically having ADD creates a situation in which possible harm is done to the child, not simply in the sense of stigma, but in treatment itself because the long term effects of drugs used to treat bipolar are not yet known. (8) There are several reasons why clinicians have difficulty in differing bipolar from conduct disorder or ADHD in children. First, childhood bipolar has not been well documented and, therefore, no official diagnostic criteria for it exist yet. (8) In addition, parents and clincians alike are more worried in treating behavioral disorders in children due to school and academic implications. Childhood bipolar is by nature more difficult to diagnose because mania in children has been found to be less episodic and instead chronic. (8) Finally, even the most current revision of the DSM had been proven ineffective in differing between the two. Carlson et al. found that 6 – 12 year old boys with mania met the criteria for ADHD as well 91% of the time. (8) The West et al. study found a similarly high rate of association of 57%. According to the current criteria, the only unique symptoms for mania are euphoria and grandiosity, which can be difficult to recognize in young children. (8) “What constitutes grandiosity, for example, at age 8 versus age 15?” (8) Therefore, the National Institute of Mental Health recommends the definition for childhood bipolar be researched further. Diagnostic criteria for ADD/ADHD currently need to be revised further because of the apparent gender bias. A study by Ohan and Johnston (1999) suggests that criteria in the DSM are male-centered. (3) As mentioned before, nearly twice as many women are labeled as suffering depression. While this could be due to the availability bias hypothesis, the significance of this gap suggests that certain gender specific behaviors are not interpreted the same possibly due to ambiguities in the criteria definitions. The ramifications of such research are not only political in nature. A 2002 Harris International

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Study found that 14% of girls versus only 5% of boys were treated with an antidepressant prior to ADD/ADHD diagnosis. This implies girls are more often mislabeled as suffering from depression and treated accordingly when stimulants are often rather the proper medical treatment. (3) It is important to note that all barriers to proper medical diagnosis are not simply due to a lack of research and/or understanding of specific mental disorders. Given the current state of managed healthcare in the United States, mental health professionals are often forced to list improper diagnoses for billing and reimbursement purposes. Regular medical physicians may not be reimbursed if they enter a mental health diagnosis. This is often not a problem concerning treatment in the clinical setting, although it requires that physicians substitute the proper diagnosis for another. Chronic fatigue syndrome, sleep disturbance, and weight loss or gain are often substituted for a diagnosis of depression. (9) How prevalent is this problem? Over a two week period, it was found that half of family doctors studied admitted to substituting a diagnosis for this reason. (Rost et al.) (9) Likewise, mental health professionals, such as clinical psychologists, may not be reimbursed if they do not list a DSM diagnosis. Therefore, these professionals often find it difficult to list relationship problems, parent-child relationship problems, bereavement, and even adult sexual abuse under the current guidelines. (9) Often bereavement is substituted with adjustment disorder with depressive features, which implies the condition is more extreme than it is in reality. (9) Finally, much of the research in psychiatry relies upon medical billing forms for knowledge of the diagnosis. Therefore, even when clinicians are able to still treat their patients adequately, future research is hindered by a wealth of skewed data, providing yet another disservice to future patients.

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It is apparent that psychology will never enjoy the empirical benefits of being a purely objective science. However, this is no reason for researchers and professionals to lose sight of the need for improvements in the fields of clinical psychology and psychiatry. Patient care is often at stake since it was shown that diagnoses often determine if and what medications will be used. Historically, the majority of improvements concerning the matter of subjectivity in psychiatric diagnosis have dealt with reliability. While this is an important factor that warrants attention, there are many more ways in which clincians have trouble making accurate and unbiased clinical judgments. The human factor will always skew the level of reliability and validity to some extent; however, this discussion has proven that realistic improvements involve everything from the limitations of the current diagnostic system to the state of mental health reimbursement. Therefore, researchers and professionals should continue forth in battling clinical misdiagnosis cognizant of the success of their predecessors and optimistic of advancements to come.

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References: (1) Wierzbicki, Michael. Issues in Clinical Psychology. Boston: Allyn and Bacon, 1993. (2) Spiegel, Alex. "The Dictionary of Disorder." The New Yorker 03 Jan. 2005: 56 63. (3) Quinn, Patricia O., MD. "Misdiagnosis of Females with ADD (ADHD)." . 13 Apr. 2005. ADDvance. 13 Apr. 2005 . (4) Wadley et al.. "Diagnostic Attributions Versus Labeling: Impact of Alzheimer's Disease and Major Depression Diagnoses on Emotions, Beliefs, and Helping Intentions of Family Members." Journal of Gerontology 2001 Vol. 56B, No.4: 244 252. (5) Witztum, Eliezer. "Stigma, Labelling and Psychiatric Misdiagnosis: Origins and Outcomes." Med Law 1995 Vol. 14: 659 - 669. (6) Epstein et al.. "Are Psychiatrists' Characteristics Related to How They Care for Depression in the Medically Ill?." Psychosomatics Nov.-Dec. 2001: 482 - 488. (7) Adebimpe, Victor, MD. "Overview: White Norms and Psychiatric Diagnosis of Black Patients." American Journal of Psychiatry March 1981: 279 - 284. (8) Kim, Eunice. "Childhood mania, attention deficit hyperactivity disorder and conduct disorder: a critical review of diagnostic dilemmas." Bipolar Disorders 2002: 4: 215 - 225. (9) Pomerantz, Jay, MD. "Deliberate Misdiagnoses of Behavioral Disorders: How Widespread?." Behavioral Health Trends Jun. 1985: 29 - 30.

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Subjectivity in psychiatric diagnosis and the implied ...

developed diagnostic system, the current mental health reimbursement ... quickly emerged and it was found that the clinicians from North Carolina often used the.

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